OPINION published: 13 January 2021 doi: 10.3389/fpsyt.2020.555559

COVID-19 Pandemic as the Beginning of a Golden Era for Telepsychiatry in Poland’s Healthcare System

Łukasz Zadka 1,2*† and Marcin Olajossy 2,3†

1 Division of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, Wroclaw, Poland, 2 Polish Psychiatric Association, Warsaw, Poland, 3 2nd Department of and Psychiatric Rehabilitation Medical University of Lublin, Medical University of Lublin, Lublin, Poland

Keywords: telepsychiatry, , e-health, COVID-19, Poland

BACKGROUND

The COVID-19 pandemic has had a tragic impact on the health and economy sectors of many countries in the world. The deepening social isolation resulting from limited interpersonal contact, the need for quarantine, overloaded healthcare professionals, and the increasing feeling of global Edited by: Gian Mauro Manzoni, fear, may lead to long-term deterioration in the mental health of societies and outweigh the losses University of eCampus, Italy of the current crisis (1). The new coronavirus has also become an attractive topic for mass media outlets that are Reviewed by: Maurice Mars, outdoing each other in informing the public about the current infection and death rates. At the University of KwaZulu-Natal, beginning of March (2), a media campaign was launched in Poland against some patients with South Africa COVID-19. The published articles emphasized the fact that infected persons had returned from *Correspondence: foreign travels to the country, which caused strong public outrage and accusations of deliberately Łukasz Zadka bringing the virus to Poland. Stigmatization of infected people by mass media particularly affected [email protected] unaware doctors returning to Poland after a vacation during that time period (3, 4). An avalanche of negative online comments caused by the published articles has led to threats against those †ORCID: physicians, and consequently even to (5, 6). The hate wave is a well-known phenomenon Łukasz Zadka orcid.org/0000-0001-5217-1635 that increases the risk of aggression and the percentage of committed , that requires the use Marcin Olajossy of appropriate strategies to prevent the spread of these adverse social impacts (7). orcid.org/0000-0002-1001-3185 FEAR OF THE UNKNOWN Specialty section: This article was submitted to Telepsychiatry is a term first introduced in 1973 by Dwyer (8), that in the current definition Public Mental Health, is a broad issue and refers to activities carried out with information and communications a section of the journal technology (ICT) for the provision or support of psychiatric services at a distance (9). Despite Frontiers in Psychiatry numerous reports of beneficial effects of e-platforms on mental health (9–11), in the Polish medical Received: 27 April 2020 community it was a topic of little interest. One possible reason was the later acceptance of this Accepted: 11 December 2020 therapy method, that emphasizes the fact that the Polish equivalent of the English definition Published: 13 January 2021 “telepsychiatria” was first defined in 2003 and until that time remained a widely unknown issue Citation: (12). Wojtuszek et al. found, that two-thirds of patients had never heard of this term, and yet half Zadka Ł and Olajossy M (2021) of the respondents saw the usefulness of applying telepsychiatry. In relation to physicians, 84% of COVID-19 Pandemic as the Beginning of a Golden Era for Telepsychiatry in respondents have never dealt with the practice of telepsychiatry and 64% would not like its broader Poland’s Healthcare System. implementation in routine medical practice. The article points to administrative difficulties, the Front. Psychiatry 11:555559. lack of relevant legal regulations, technological limitations, no payment for e-services, and security doi: 10.3389/fpsyt.2020.555559 issues as major obstacles to the practice of telepsychiatry (13).

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THE SNOWS OF YESTERYEAR TABLE 1 | Characteristic of telepsychiatric services available in Poland.

One of the restrictions on the use of telemedicine in Poland Subject Description was also the Medical Code of Ethics (Kodeks Etyki Lekarskiej – Service definition A remote visit (e-visit, tele-visit, online visit) KEL). Its 9th Article indicates that a physician may only start the Customer Patient identification required (identity treatment thorough a physical examination of the patient. This card), the need to provide patient’s article allows the possibility of distance treatment, but only in personal data (first and last name, the case of an urgent need (14). The interpretation of that term address, national identification number remains controversial and may be interpreted differently by the (PESEL) or the guardian’s data (for physician giving the services, and otherwise by the medical court. patients with intellectual disabilities or if incapacitated) For Poland, the most common reasons for e-consultations are Service provider Physician, psychologist, psychotherapist emergency incidents of mental health deterioration most often Recommended form of service Telephone conversation or video associated with anxiety disorders, followed by mood disorders provision consultation that ensures encrypted (15). Moreover, e-interventions have also been shown to be transmission; video communicators are beneficial to patients with schizophrenia and the therapeutic the preferred form (empathic approach itself was positively evaluated by these patients (12). patient-physician relationship; possible However, the 6th Article of KEL mentions the physician’s observation of facial expressions, reactions and patient behavior) freedom to choose the methods of follow-up that are considered Requirements Past medical history, current medical most effective. It should be noted that e-services allow patients a documentation, including the results of significant reduction in travel costs (16). Here, we should refer to laboratory tests and/or the 57th Article of the 2nd Act of KEL, which clearly states that findings the physician may ask the patient the physician is responsible for choosing the form of diagnosis to send scans of documentation by an or therapy without putting the patient at an unreasonable email or via SMS/MMS. expenditure (14). Therefore, there are no premises preventing the Responsibility The consequences of providing incorrect, incomplete, false, misleading or otherwise provision of telepsychiatry with regard to ethical concerns. incorrect data are the sole responsibility of the patient. THE METAMORPHOSES Restrictions The examination cannot fully replace a direct medical or psychological The position of the Polish government on the latest changes in examination; teleconsultation is allowed only if a direct examination cannot take the Law of December 5, 1996 on the profession of physicians place and dentists should be considered as positive. The Act allows Important reasons allowing the Epidemiological threat, forced isolation of clinicians to carry out diagnostic and therapeutic activities patient to be examined at a distance the patient or unavailability for other through ICT (17). The law as a valid legal act dispels any doubts reasons about the application of telemedicine in Poland. The positive Conditions for refunding benefits Provision of services using ICT systems at impact on the position of these services in the Polish healthcare the place of providing benefits system has also the obligation to provide e-prescriptions using ICT, Information and communications technology; SMS, Short message service; MMS, the recently introduced IT platform, which has been in place Multimedia messaging service. since January 8, 2020 (18). These changes contribute to the better Based on recommendations of the Scientific Section of Telepsychiatry of Polish Psychiatric understanding of the digitization of medical systems, that should Association (19); Regulation of the Minister of Health of 16th March, 2020 (20). lead to increased trust in the use of ICT services. Before the most recent pandemic, Polish highlighted the lack of places for patients who required the forecast of health needs in their specific field, advising on hospitalization in mental health units, which resulted in the the implementation of important tasks in the Polish healthcare inability to provide medical benefits in line with current system, and giving opinion and advice on tasks related to needs. Child and adolescent psychiatry has been particularly the training program of medical specialists. Adequate action hit by this problem, where the needs were greatest, and the by the PTP contributed to an immediate change in Polish level of underfinancing remained high. The pandemic crisis legislation for the provision of on-line services. The latest PTP caused concern associated with the obvious determinative state recommendations are summarized in Table 1. of the health status of patients who were in remission and the expected acceleration of mental health problems in the general population. The Polish Psychiatric Association (PTP) THE REVOLUTION - TELEMEDICAL and the national psychiatry consultant took the initiative by SERVICES ARE JUST AS IMPORTANT AS making appropriate statements addressed to both the Ministry AN IN-PERSON VISIT of Health and the National Health Fund of Poland. National consultants are appointed by the Minister of Health from among The Polish Chamber of Physicians and Dentists (Naczelna specialists in particular fields and their duties include but are Izba Lekarska - NIL) at a meeting on July 24, 2020 adopted not limited to: the initiation of national epidemiological research, an act on the recognition of guidelines for the provision of

Frontiers in Psychiatry | www.frontiersin.org 2 January 2021 | Volume 11 | Article 555559 Zadka and Olajossy COVID-19 Positively Influenced Telepsychiatry in Poland telemedicine services along with the recommendation of its - Telemedicine is a recognized method of patient care, and thus use by physicians and dentists as part of their profession. As it can be treated as one of the standards of medical treatment. highlighted, a significant contribution in the legislative work - The medical practitioner should use the potential of should be attributed to the statements made by Polish medical telemedicine to realize the patient’s rights. societies and recently implemented changes to the legal norms - Telemedicine enables the implementation of individual (21). Moreover, the Presidium of NIL called on the Minister of patient rights in a new, digital way. Health to undertake prompt steps leading to the introduction - Telemedicine advice should not be disregarded due to its of proposed guidelines as an existing standard for the Polish remote form. The rules of professional, civil, and criminal healthcare system (22, 23). The appeal took into account the liability for telemedicine services are the same as in the case of benefits of implementing telemedicine services into routine other services, and the recipient receives all rights pertaining medical practice, as well as the negative impact of the COVID- to a patient. 19 pandemic which required adequate action, justifying the The adopted guidelines constitute a decisive and important immediate use of ICT services. turnaround to the previously discussed limitations of the Obviously, the provision of telemedicine services must be implementation of telemedicine services resulting from some consistent with the Polish legal system. The emphasis was articles of KEL. placed on the issue of the security of the patient’s personal data and medical data, emphasizing the need to maintain medical confidentiality when performing e-services. Healthcare IT IS TOO SOON FOR THE EPILOG institutions providing e-services in the field of telemedicine The updates incorporated into the Polish healthcare sector are required to secure data transmission and enable optimal are moving in the right direction. In our opinion, previously accessibility to such services for every recipient. This means hospitalized patients on long-term treatment will benefit the ensuring appropriate system requirements, securing the network, most. Many of them are often in contact by phone to provide and providing facilities with all electronic tools needed to expert support. There are still doubts to first-time treated enable e-consultation with a patient. With regard to medical patients, where the diagnosis, often in psychiatry, is based practitioners, the appropriate amendments to professional on medical history and may be difficult, thus actions taken liability related to the provision of telemedicine services have will be at risk. However, it should be noted that in the face been taken into account, in light of which the use of telemedicine of the current pandemic, special care is required for patients is not only highly recommended, but also mandatory when the with anxiety disorders. Panic and behavioral change due to patient’s condition requires it. If a physician fails to provide e- the necessity of wearing gloves and medical masks to protect services, when available and required, they could be held legally against the contamination by the new coronavirus may increase liable for malpractice. The healthcare entities employing medical anxiety and polarize the current problems in the direction of staff are now responsible for their mistakes resulting from given a “coronaphobia” (24). The increased availability of e-services e-services, if the employee was hired under an employment will also intensify the phenomenon of the deinstitutionalization contract. In case of a contract physician, the liability rules will of Polish psychiatry, will help patients gain access to medical be enforced individually on the basis of the concluded contract. specialists, and it will reduce the difficulties included with a A need to use telemedicine services during the limited number of hospital beds. Therefore, we look forward to COVID-19 pandemic was noticed, which was emphasized the future with optimism. in the prepared guidelines as well as in the written communication to the Minister of Health. An additional interpretation was also introduced in relation to the previous AUTHOR CONTRIBUTIONS rules of medical ethics, which previously limited the implementation of e-services, thus a physical examination ŁZ: study design, preparation of the manuscript in Polish and of the patient is currently recommended only in cases English, and selection of references, MO: correction of the Polish where it is necessary to perform it. The following NIL version of the manuscript and selection of references. All authors directives, included in the guidelines, are particularly significantly contributed to the writing of the manuscript and worth emphasizing: approved its final version.

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